The institute of Medicine's recent report on geographic variation in Medicare spending found that spending for post-acute care is the single biggest cause for the variation. Medicare spends nearly as much on post- acute care and readmission as it does for the original admission in patients hospitalized for conditions such as CHF, pneumonia and COPD. Changes in post-acute care have been rapid and complex, driven by changes in models of reimbursement. We have shown that strategies to reduce cost of hospitalization can contribute to decreased continuity of care, increased readmissions, and greater overall Medicare costs. There is surprisingly little information on the trajectories of car involving hospitalized patients. Over the past five years we have begun to describe the complex trajectories of care of hospitalized patients using Medicare data. A previously unexamined but important adverse outcome of hospitalization is a permanent transfer to long term care of individuals who previously resided in the community. We found that three quarters of all new admissions to long term care (LTC) nursing homes (not SNFs) are preceded by a hospitalization. In most of those cases the patient was initially discharged to a SNF, and later transferred to a LTC nursing home. We now wish to turn our full attention to post hospital care, addressing the following Specific Aims: 1. Estimate the rate of patients ultimately residing in a long term care nursing home after hospitalization and after a SNF stay in the U.S, their length of stay once admitted to a LTC nursing home, the percent that are ultimately discharged from the LTC nursing home to the community, and patient characteristics associated with these outcomes. 2. Determine hospital-level and SNF-level factors associated with risk of subsequent long term care, independent of patient-level factors. Hospital level factors include size, ownership, teaching status, the adjusted percentage of its inpatients that are discharged to SNFs, and hospital quality ratings. SNF level factors include size, ownership, whether it also has long term care beds, staffing patterns, and quality ratings. 3. Assess the impact of state regulations and changes in federal and state regulations on rates of LTC post-hospitalization and post SNF. State regulations will be assessed directly (e.g. participation in the Money Follows the Person initiative) and indirectly (e.g. long term nursing home bed supply, supply of community alternatives to institutionalization).